donor identification and referral

Organ Donation Past, Present and Future

Donor Identification and Referral

Jacki NewbyDr Huw Twamley3rd July 2013

1

NORTHERN


Regional Data

2

Jacki Newby

NORTHERN

-------- National rate

95 97

8893

98

86 8791

95

8489 89

Ref

erra

l rat

e (%

)

0

20

40

60

80

100

Team

Easter

n

London

Midlands

North

West

Northern

Northern

Irelan

dSco

tland

South

Centra

lSouth

East

South

Wales South

West

Yorks

hire

1 April 2012 to 31 March 2013, data as at 4 April 2013

1st

Organ Donation Past, Present and Future 3

Northern DBD referral rateNORTHERN

Ref

erra

l rat

e (%

)

0

20

40

60

80

100

Number of neurological death suspected patients0 10 20 30 40

1 234 56 789

Trust National rate 95% Lower CL95% Upper CL 99.8% Lower CL 99.8% Upper CL



Northern DBD referral rate

1 South Tyneside NHS Foundation Trust

2 City Hospitals Sunderland NHS Foundation Trust

3 North Cumbria University Hospitals NHS Trust

4 Gateshead Health NHS Foundation Trust

5 The Newcastle Upon Tyne Hospitals NHS Foundation Trust

6 Northumbria Healthcare NHS Foundation Trust

7 South Tees Hospitals NHS Foundation Trust

8 North Tees and Hartlepool NHS Foundation Trust

9 County Durham and Darlington NHS Foundation Trust

NORTHERN

-------- National rate

80

72

54

72

81

52

42

54 5659 60

65

Ref

erra

l rat

e (%

)

0

20

40

60

80

100

Team

Easter

n

London

Midlands

North

West

Northern

Northern

Irelan

dSco

tland

South

Centra

lSouth

East

South

Wales

South

West

Yorkshire



Northern DCD referral rateNORTHERN

1st


Northern DCD referral rate


Ref

erra

l rat

e (%

)

0

20

40

60

80

100

Number of imminent death anticipated patients0 10 20 30 40 50 60 70 80 90 100 110 120 130

1

2

3

4

56

7

8

9

Trust National rate 95% Lower CL95% Upper CL 99.8% Lower CL 99.8% Upper CL

1 South Tyneside NHS Foundation Trust

2 City Hospitals Sunderland NHS Foundation Trust

3 North Cumbria University Hospitals NHS Trust

4 Gateshead Health NHS Foundation Trust

5 The Newcastle Upon Tyne Hospitals NHS Foundation Trust

6 Northumbria Healthcare NHS Foundation Trust

7 South Tees Hospitals NHS Foundation Trust

8 North Tees and Hartlepool NHS Foundation Trust

9 County Durham and Darlington NHS Foundation Trust

Northern Referral Process

Jacki NewbyNorthern Organ Donation Team

July 3rd 2013

History Lesson

• In 2010 SNOD’s asked for 100% referral of BSD testing and WLST REGARDLESS OF AGE OR CLINICAL CONDITION.

• Clinicians agreed if we met 2 factors

– SPEED = We needed to have a speedy process for deciding donation potential.

– ETHICS = We agreed we would only approach the families of patients who had donation potential, meaning we would provisionally place organs before approaching families.

Jacki Newby – Northern Organ Donation Team

The Northern Referral Model

• Is a means of standardising the referral process, and standardising our SNOD response to each referral.

• A process that is measurable, equitable, transparent and quick.

• A 2 part system answering 2 separate questions – is the patient suitable to donate– have they organs suitable to transplant

NORTHERN REFERRAL PROCESS (to be used with NHSDBT referral form FRM 4228)

Age >85yrearsAre there any Absolute Contraindications = see below

Are there plans to perform BSD tests

YES

NO

Does the patient have any ABSOLUTE CONTRAINDICATIONSDoes the patient have cancer with evidence of spread (including lymph nodes) within 3years (localised prostate, thyroid, insitu cervical cancer & non melanotic skin cancer are acceptable) haematological cancer (myeloma, lymphoma, leukaemia) malignant melanoma (except excised Stage 1) a confirmed / suspected prion disease human TSE CJD & vCJD, familial CJD ) : active HIV disease (not infection) : TB active & untreated

YESDecline donation from this patient

and advise re corneas

NO Attend unit to assess patient

Is the patient over 85 YES Decline donation and advise re tissues

NO

YESNO Decline donation and advise regarding corneas

Is the patients systolic over 50mmHg NO Decline donation as this patient is already in FWITand advise regarding corneas or other tissue

YES

Is the patient unstable (systolic between 50 and 75mmHg) YES

Ask medical staff to consider measures to stabilise the patient (fluids, inotropes, increased ventilation etc) if they cannot or will not,

and inevitable death is expected within 2 hours decline donation. This patient is in the dying process and there is no time to

facilitate donation: advise about corneas and tissue

NO

Do medical staff believe that withdrawalof care will result in death within 6 hours

YES

NODecline donation as this patient is not expected

to die within timeframes for donation

THIS PATIENT IS A POTENTIAL DONOR: TAKE FULL REFERRAL DETAILS AND FOLLOW REFERRAL PROCESS

• Page 1 gives a quick answer for those patients who are not suitable to donate.

• In some regions SNOD’s will attend the unit to determine donation potential; in Northern we do this by phone.

• In some regions referrals are taken to a team manager or regional manager to decide donation potential; here our system decides.

• Once the SNOD has established they are a potential donor we look at every organ and the donation potential of each organ.

SPEED

Consider kidney donation as its the organ most likely to be acceptedDoes the patient have established renal failure documented CKD stage 3B or higher;

normal GFR <45, or has had a kidney transplant for longer than 6 months, or do they have renal malignancy (low grade & previously excised tumours may be considered)

NO

YES

Discuss possible donation with 6 recipient centres. If a centre states they would accept stop offering to other centres

and approach family; offering of other organs is as usual using EOS and fast tracking.

Rule out kidney donationconcentrate on LIVER; does the patient have a diagnosed

cirrhosis, portal vein thrombosis or have acute liver failure with ALT / AST > 1000

YES

NO

Rule out liver donation:and concentrate on LUNGS.Does the patient aged over 65, has intra-thoracic malignancy; major consolidation on CXR; orchronic destructive or suppurative lung disease

YES

Rule out lung donation: consider PANCREAS donation; is the

patient aged over 65, do they have type I diabetes or pancreatic malignancy

NO

NO

YES

This patient has no organs which are suitable for donation: Explain this to referring unit and discuss tissue / corneal donation

Discuss possible donation with all recipient centres using offering form. If a centre states they would accept stop offering to other centres and approach family.

Offering of other organs is as usual using EOS and fast tracking.

Discuss possible donation with 5 recipient centres using offering form. If a centre states they would accept stop offering to other centres and approach family.

Offering of other organs is as usual using EOS and fast tracking.

Discuss possible donation with 3 recipient centres using offering form. If a centre states they would accept stop offering to other centres and approach family.

If no centres accept:- this patient has organs which have not been accepted by transplant centres. Explain to referring unit and discuss tissue / corneas.

• Page 2 allows us to either – Decline organs using James Neuberger’s criteria – Or ask transplanting centres if they would accept organs from this

patient.

• 30% of non proceeding DCD donations are due to organs being declined by transplanting centres (134 cases in 2012)

• In 2012 the Northern Region took consent from only 3 patients who had organs declined by centres.

ETHICS

Lessons learned from an audit of 451 referrals• Referrals take time, the key is to refer before talking to a family.

• 56% of all referrals are quickly declined by the SNOD.

• 44% referrals taken to transplanting centres

– 49% accepted: of these 82% are accepted by the first centre contacted

– 51% declined: average time to screen is 2 hours

• Some patients were always declined (ischemic bowel, ruptured AAA, OOHCA in pts over 75) more work is needed on criteria.

• The system works

Jacki Newby – Northern Organ Donation team


Identification and Referral

17

Dr Huw TwamleyNorth West Regional CLOD

Timely Identification and

Referral of Potential Organ Donors


www.odt.nhs.uk

18

Session Objectives

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• Understand difficulties with donor identification and referral

• Recognise benefits of improving elements of the process– Increased identification and referral– Timely referral– Responsiveness to referral

• Consider which of the proposed methods of identification and referral may work in your hospital


UK rates of referral

referral of deceased donors

0

20

40

60

80

100

2005-6 2006-7 2007-8 2008-9 2009-10 2010-11 2011-12

year

perc

enta

ge

DBD DCD


91%

52%

20

Overall timings


Aims of Strategy• 100% Identification of potential

Donors

• 100% Referral of Potential Donors

• 100% Timely Referral

• Implement NICE Guidance

The consideration of donation should be core ICU / ED and part of all end of life care plans.

Timely referral promotes this possibility


NICE Guideline 135


British Medical Association 2012

The research data -------- showed that the use of clinical triggers and a requirement to refer according to standard criteria led to an increase in both referrals and donors. It is hoped that implementation of the NICE guideline will result in early and consistent donor referral.


General Medical Council 2010

“If a patient is close to death and their views cannot be determined, you should be prepared to explore with those close to them whether they had expressed any views about organ or tissue donation, if donation is likely to be a possibility.”

“You should follow any national procedures for identifying potential organ donors and, in appropriate cases, for notifying the local transplant coordinator.”

Decisions to limit or withdraw treatments in potential DCD donors MUST be in compliance with national End of Life Care policy.


UK Donation Ethics Committee

“There is no ethical dilemma if the treating clinician wishes to make contact with the SN-OD at an early stage, while the patient is seriously ill and death is likely, but before a formal decision has been made to withdraw life-sustaining treatment.”

[“Benefits] include establishing whether there are contra-indications for organ donation……

Other practical and organisational factors might be relevant – if the SN-OD is based at a distant location then early contact can help to minimise distressing delays for the family.”


Objectives, benefits and outcomesAll potential donors are identified and referred

All donors are referred in a timely fashion

SN-ODs are deployed in a way that improves responsiveness

All patients are given the option of donation

Access to clinical advicePrompt donor optimisationResolution of potential legal obstaclesEarly assessment of marginal donorsEarly tissue typing / screeningPlanning the family approach

Reduction in delays for families and units

Increased donor numbersImproved consent / authorisation ratesIncrease in donor organsBetter experience for families and staff


NHSBT Strategy

• Implementation not publication• Key area for collaboration

between hospitals and donor care teams

• Very clear emphasis on benefits– How not who

• Suite of options• Clarity over implementation


Strategy proposals

• Every hospital should have a written policy for the identification and timely referral of all potential donors

• Every donating area within a given hospital adopts a consistent approach

• As far as possible ‘decouple’ early referral from individual clinician

Donation Committees and SN-OD teams should collaborate to develop and implement a policy that ensures that all potential donors are identified and referred in a timely fashion.


1. Daily visit by SN-OD


2. Early daily phone call


3. Daily ICU team safety brief



North Bristol Trust ICU Safety Brief

33

4. Standard Operating Procedure


Midlands Standard Operating Procedure

35Organ Donation Past, Present and Future

5. Nurse led referrals


Summary

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• Donation should be a element of end of life care

• Make identification and referral routine business of the unit.

• This decouples early referral from the individual clinician caring for the patient

• Implement or develop a solutions /policy for your individual hospitals adopt to timely referral

• Ensure consistency within a given hospital


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Apr

il - S

epte

mbe

r 201

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Oct

ober

201

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arch

201

1

Apr

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1

Oct

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201

1 - M

arch

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Apr

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Oct

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500

1000

1500

2000

2500

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3500

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Number of audited referrals and actual donors reported through the Referral Record, data as at 9 May 2013

Num

ber o

f pat

ient

s


What are the barriers to implementing the NICE guidelines in your unit: any solutions?

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Whichever is the earlier, either:

Use trigger factors in patients with a catastrophic brain injury The absence of one or more cranial nerve reflexes

AND a GCS of 4 or less that is not explained by sedation

And / or a decision is made to perform brainstem death tests.

The intention to withdraw life-sustaining treatment in patients with a life-threatening or life-limiting condition which will, or is expected to, result in circulatory death.


donor identification and referral

Documents

storgan donation past

individual hospitals

donation poten

future snod

northern dcd referral

future intro

referral of bsd testing

snod dcd potential cases